Why checking before you go matters so much
Most surprise medical bills are preventable. The problem is not that the healthcare system is designed to surprise you (though some critics would argue otherwise) — it is that the system assumes you already know how it works. You are expected to verify your own coverage, obtain your own prior authorizations, confirm that every provider involved in your care is in-network, and get cost estimates in advance.
If you do not do these things, you may find out after the fact that your insurance does not cover the procedure, that one of the providers was out-of-network, or that you needed a prior authorization that was never obtained. By then, you are facing a bill that could have been avoided.
The No Surprises Act (effective January 2022) provides significant new protections, but it does not cover everything. The Act protects you from surprise out-of-network bills in emergency situations and at in-network facilities — but it does not protect you from choosing an out-of-network facility, from services that are not covered under your plan, or from prior authorization failures.
Step 1: Verify that the procedure is covered
Before scheduling any procedure, call the member services number on the back of your insurance card and ask these specific questions:
Is this procedure covered under my specific plan?
Not all plans cover all procedures. Ask them to verify using the exact CPT code (your provider can give you this). Get a reference number for the call.
Are there any exclusions or limitations?
Some plans cover a procedure but with limitations — for example, only at certain facilities, only after other treatments have failed, or only a certain number of times per year.
What is my cost-sharing for this procedure?
Ask specifically what your deductible, copay, and coinsurance will be. Ask how much of your deductible you have already met this year. Request a dollar estimate of your out-of-pocket cost.
Does this require prior authorization?
If yes, ask who is responsible for obtaining it — you or your provider. Do not assume the provider will handle it. Confirm prior auth has been obtained before the procedure date.
Is the specific facility where the procedure will be performed in-network?
It is possible for a doctor to be in-network but the facility they operate at to be out-of-network. Verify both the provider AND the facility.
Write down the name of the representative you spoke with, the date and time of the call, and the reference number. If the insurer later denies coverage for a procedure they confirmed was covered, this documentation becomes your evidence for an appeal.
Step 2: Handle prior authorization properly
Prior authorization (also called “pre-auth” or “pre-certification”) is a requirement by many insurers that a procedure be approved before it is performed. According to the AMA, 88% of physicians report that prior authorization requirements have increased over the past 5 years, and the average medical practice completes 43 prior authorizations per physician per week.
If your procedure requires prior authorization, here is what you need to do:
Confirm whether prior auth is required
Ask your insurer directly. Do not rely on your provider to know — they may assume it is not needed for your specific plan. Get the answer in writing or note the reference number.
Confirm who will submit the request
Usually the provider submits the prior auth request, but you need to verify this. Ask your provider: "Have you submitted the prior authorization? What is the authorization number?"
Follow up before the procedure date
Do not assume the prior auth was approved just because the provider submitted it. Call your insurer 3-5 business days before the procedure to confirm the authorization is in place. Get the authorization number.
Know what to do if prior auth is denied
If the insurer denies the prior authorization, you have the right to appeal. Your provider can submit a peer-to-peer review (a conversation between your doctor and the insurer's medical reviewer). This is often the fastest way to get an approval — 82% of prior auth appeals succeed (AMA, 2024).
Check your coverage before you go
Upload your plan documents or EOB and Lysco will help you understand what is covered, what your cost-sharing looks like, and what questions to ask before your procedure.
Check your coverage — freeStep 3: Verify EVERY provider is in-network
One of the most common sources of surprise bills is out-of-network providers you did not choose. During a hospital stay or surgical procedure, multiple providers may be involved — surgeon, anesthesiologist, radiologist, pathologist, assistant surgeon — and not all of them may be in your insurance network.
Before your procedure, ask your surgeon or scheduling coordinator:
- “Who else will be involved in my care?” Get the names of the anesthesiologist, radiologist, pathologist, and any other providers who will participate.
- “Are all of these providers in my insurance network?” Verify each one with your insurer, not just with the provider office. Provider directories can be outdated.
- “Can you guarantee in-network providers only?” If the facility cannot guarantee this, ask them to document in writing that they will not assign out-of-network providers to your case. If they cannot, know that the No Surprises Act may still protect you.
No Surprises Act protection
Under the No Surprises Act (effective January 2022), you are protected from surprise out-of-network bills for: (1) emergency services at any facility, (2) non-emergency services from out-of-network providers at in-network facilities (unless you signed a written consent to waive protection at least 72 hours in advance), and (3) air ambulance services. If you are billed in violation of these protections, file a complaint at cms.gov/nosurprises.
Step 4: Get a cost estimate in advance
You have the right to know what a procedure will cost before you agree to it. Here are your options:
Good Faith Estimate (GFE)
Under the No Surprises Act, if you are uninsured or self-pay, you have the right to a Good Faith Estimate of the total expected cost before any scheduled service. The provider must give this to you in writing at least 1 business day before the service (3 business days if you schedule further in advance). If the final bill is more than $400 above the GFE, you can dispute it through the federal Patient-Provider Dispute Resolution process.
Insurer cost estimator tools
Most major insurers (UnitedHealthcare, Anthem, Aetna, Cigna, Blue Cross) offer online cost estimator tools through their member portals. These tools use the specific CPT code and your plan details to estimate your out-of-pocket cost. The estimates are not always perfectly accurate, but they give you a ballpark.
Hospital price transparency
Since January 2021, all hospitals are required by CMS to publish their negotiated rates in a machine-readable format. Many now also offer patient-friendly price lookup tools on their websites. Check the hospital website for a “price transparency” or “cost estimator” page.
Step 5: Consider alternatives
Before committing to a procedure at a specific facility, consider whether you can reduce your cost by:
- Having the procedure at an ambulatory surgery center (ASC) instead of a hospital outpatient department. The same procedure performed at an ASC is often 30-60% cheaper than at a hospital because ASCs have lower facility fees. Ask your surgeon if the procedure can be done at an ASC.
- Comparing prices across facilities. Using hospital price transparency data and tools like FAIR Health, you can compare the cost of the same procedure at different in-network facilities in your area. Price differences of 2-5x for the same procedure are common.
- Timing the procedure around your deductible. If you have already met most of your annual deductible, scheduling the procedure this year means your insurer will cover a larger share. If you have barely touched your deductible and the procedure is not urgent, consider timing.
- Asking about cash-pay pricing. Some facilities offer a self-pay or cash-pay price that is lower than the insured price — especially for imaging (MRI, CT scan) and routine procedures. If your deductible is high and you are paying most of the cost out of pocket anyway, a cash-pay price may save you money.
Your complete pre-procedure checklist
Use this checklist before any scheduled medical procedure. Print it or save it for reference:
- 1Call your insurer — confirm the procedure is covered under your specific plan (get reference number)
- 2Ask about exclusions, limitations, and pre-existing condition waiting periods
- 3Ask if prior authorization is required — if yes, confirm it has been obtained and get the auth number
- 4Verify the facility is in-network with your plan
- 5Ask the surgeon who else will be involved (anesthesia, radiology, pathology, etc.)
- 6Verify every provider involved is in-network
- 7Request a cost estimate from your insurer (use their online tool or call)
- 8Request a Good Faith Estimate from the provider (required by law for self-pay patients)
- 9Check if the procedure can be done at a lower-cost ambulatory surgery center
- 10Compare prices across facilities using hospital transparency data
- 11Review your deductible status — how much have you met this year?
- 12Document everything — names, dates, reference numbers, authorization numbers
If you get a surprise bill anyway
Even with preparation, surprise bills can happen. If you receive one:
- Check if the No Surprises Act applies. If the surprise bill is from an out-of-network provider at an in-network facility, or from emergency services, you are likely protected. File a complaint at cms.gov/nosurprises.
- Compare the bill to your Good Faith Estimate. If the bill exceeds the GFE by more than $400, you can dispute it through the federal Patient-Provider Dispute Resolution process.
- Appeal through your insurer if the bill resulted from a coverage denial or prior auth failure. See our guide on how to appeal an insurance denial.
- Negotiate the bill if you owe a legitimate out-of-pocket amount that is too high. See our guide on what to do when your medical bill is too high.
Upcoming procedure?
Check your coverage and avoid surprise bills before you go
Get Started FreeGet our free Healthcare Savings Guide
Join thousands of patients fighting back against unfair medical bills.
Start Fighting Back — FreeDisclaimer: This guide provides general information about medical procedures and insurance coverage. It is not medical or legal advice. Plan terms and provider policies vary. For personal advice, talk to your insurer or a licensed professional.
Check your coverage before you go
Upload your plan documents and Lysco will help you understand what is covered, what your costs will look like, and what to verify with your insurer.
Get Started FreeNo credit card required.